Mountain Empire Community College-TS

Educational Talent Search
A federally funded TRIO Program
Funded to serve 655 participants

Mountain Empire Community College
3441 Mountain Empire Road
Big Stone Gap, VA 24219
276-523-2400, Ext. 333

Financial Information Request Form
To be completed by the student's parent'(s) or guardian(s)

Since you or your child has indicated an interest in participating in the Talent Search program, please complete the following information and return to our office as soon as possible. All information shared with the MECC Talent Search program is strictly confidential and is used only to determine eligibility for services for the Talent Search program.
1. How many people (including the student) are in the household?*

Household Members

	Name	Relationship to Student
1
2
3
4
5
6
7

2. Does either parent/guardian with whom the student lives have a four – year (Bachelor's) degree?*

YesNo
SECTION A
1. From your most recent Federal Income Tax Return, fill in your taxable income.*
(This information can be found on line 43 of the IRS 1040 or line 27 ofIRS 1040A or line 6 of IRS 1040EZ)
2. If any or all of your income was not taxed, please identify source(s) of income*

UnemploymentSocial SecurityWelfare benefitsChild supportAll of my income is taxedOther
3. Does anyone in the house qualify for

Free School LunchWICReduced Price School LunchSNAP BenefitsSSITANF
SECTION B
AUTHORIZATION FOR INFORMATION RELEASE

The information reported on this form is true, correct, and complete to the best of my (our) knowledge. The Talent Search program (TS) is authorized to make whatever contacts necessary for securing educational and financial information about my son/daughter, and my signature serves as consent for release of such information to TS. I understand that access to educational records is essential for TS to serve my son’s/daughter’s needs, and income information is necessary in order to determine my son’s/daughter’s eligibility for program services. My signature also gives permission to publish name and/or photographs of my son/daughter for TS promotional material. I understand that all personal information will be held in the strictest confidence according to federal and state guidelines.
Parent's/Guardian's Printed Name*

First NameLast Name
Parent's/Guardian'sSignature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Email*
example@example.com
Parent/Guardian Phone*
(999)999-9999
All applications are accepted for review regardless of race, color, national origin,
religion, gender, or disability.

US Department of Education - GEPA Section 427